‘Little Emperors’ Wage War on China’s Deadliest Killers

For decades, doctors battling stroke and heart disease have struggled to get the Chinese to eat less salt. Researchers now have one solution: train school kids to push their parents to cut back.

Counting on the influence of these “little emperors,” a group of researchers taught school children in the northern province of Shanxi the harmful effects of their traditional salty diet. They then asked them to take the message to adults back home.

One boy chose to empty the family’s kitchen salt jar into the toilet, leaving his parents furious. Another student hid his mother’s salt and then promptly forgot where he had put it. But in a little under four months, the salt intake of participants had plunged by a quarter.

Across China, salty stews and hotpots are popular dinner fare, and an estimated 270 million Chinese now suffer from hypertension. In 2013, stroke was the number one killer in China, with ischaemic heart disease taking the second most number of years from Chinese lives prematurely, according to a global mortality report published by the Lancet in December. The report measured the effects of each type of cancer separately.

In the absence of a scaled-up government response, cardiovascular disease, stroke and diabetes are expected to result in a loss of about $550 billion in China’s national income between 2005 and 2015, according to the World Health Organization.

Only Child

Seeking long-term solutions, researchers from the non-profit George Institute for Global Health decided to do the research among kids because of the unusual clout Chinese children have in their families. Many are the family’s sole offspring because of China’s one-child policy, leading to the nickname “little emperor.”

“In China, kids have a special status in the family,” said Zhang Jing, research fellow at the China office of the George Institute. “They can say to their family: I won’t eat it if you cook very salty food.”

The Chinese on average eat 12 grams of salt a day, according to the country’s health ministry. Salt intake of less than 5 grams per day for adults helps to reduce blood pressure and the risk of cardiovascular disease, stroke and coronary heart attack, according to the WHO.

China’s overburdened health-care system is ill-equipped to handle the growing stream of hypertension patients and prevent the 2 million related deaths each year. Despite government efforts, such as subsidies for hypertension drugs, incidence of the condition and deaths from heart disease and stroke continue rising, according to Wu Yangfeng, senior director of George Institute’s China office. China’s National Health and Family Planning Commission didn’t respond to a call and fax seeking comment.

There is a C-shaped stroke belt in north and west China consisting of nine provincial areas where stroke incidence was 236.2 per 100,000 people, more than twice that in other regions, according to a study published in 2013 by the American Heart Association’s Stroke journal. The stroke belt may be caused, at least in part, by a higher prevalence of hypertension and excess body weight, according to the study.

Americans eat about 8.7 grams of salt each day, three quarters of which comes from processed food, according to the Pan American Health Organization, a regional office of the WHO. Heart disease is the leading cause of death in the U.S., killing about 600,000, according to the U.S. Centers for Disease Control and Prevention while stroke kills almost 130,000.

Old Battle

China’s battle against salt began years ago. Liu Lisheng, an 87-year-old heart disease doctor by training and the former president of the World Hypertension League, has been campaigning for hypertension prevention and control since Mao Zedong’s Great Leap Forward in 1960. The slogan they chanted then was: “make hypertension lower its head and make cancer give way.” Reforming China’s salty taste has proven a challenge even though salt isn’t addictive like nicotine, said Liu.

“Lifestyle is very difficult to change once the palate is used to a certain degree of saltiness,” said Liu, who wasn’t involved in the George Institute study. “If you teach children to not get used to salty food when they are young, they will eat less salt when they grow up.”

The George Institute researchers felt that educating children might pay off better than directly appealing to adults with life-long preference for savory cuisines, and could be a cheap and effective public health intervention.

Unlike in developed countries where most salt is consumed through processed or restaurant food, Chinese eat their salt primarily from home cooking, especially in rural areas, according to the George Institute.

Smaller Spoons

From September to December 2013, about 280 students participated in the study along with 560 adults, about two-thirds of whom were parents. The rest were grandparents. During nine sessions children were taught that salt can contribute to hypertension, stroke and stomach cancer, and given tips on salt reduction: use smaller spoons for seasoning, eat less pickle and avoid tasty instant noodles. The kids were around the age of 11.

They were also taught catchy phrases in Chinese: “Cilantro and sesame paste, tasty and not salty” and “season with onion, ginger and garlic, sour and spicy also tasty” to help redirect their families’ preferences away from salty dishes.

The fifth-graders managed to cut their parents and grandparents’ daily salt intake from 12.6 grams to 10.4 grams, a 25 percent drop when adjusted for seasonal changes in their diet, according to the researchers. The measure for the kids decreased by 27 percent, according to Zhang, manager of the study, which is expected to be published soon. The researchers declined to name any of the children or families involved.

Reducing the average Chinese person’s salt intake by a gram a day can save 125,000 lives a year, the George Institute estimates.

“Treating people with drugs after they’re already sick is too slow and too late, and fails to have a preventive effect and truly keep the population healthy,” Wu said. “But salt is something that everybody eats. ”